European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 119–125

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review

Uterine myomas revisited

Nirmala Duhan *, Daya Sirohiwal
Department of Obstetrics and Gynecology, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

A R T I C L E I N F O A B S T R A C T

Article history: The present study was planned to review the pathophysiology of uterine myomas and emphasize the
Received 29 October 2009 principles of logical management on the basis of literature review and synthesis of the author’s
Received in revised form 17 April 2010 experience. The growth of uterine myomas, the most common solid pelvic tumors in women, is related to
Accepted 24 May 2010
genetic predisposition, hormonal influences and growth factors. The treatment options include
pharmacologic, surgical and radiographic interventions. Most asymptomatic myomas can be followed
Keywords: serially for progressive growth or development of symptoms. The various diagnostic and therapeutic
Uterine myomas
advancements available today permit higher management flexibility with safe options, which must be
Development
Management
tailored to the individual patients requirement.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
2. Clinical features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
3. Growth patterns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
4. Treatment options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5. Hormone treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
6. Indications for surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
6.1. Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
6.2. Abdominal myomectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
6.3. Hysteroscopic myomectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.4. Laparoscopic/robotically assisted laparoscopic myomectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.5. Uterine artery embolization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.6. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
6.7. Myolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
7. Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

1. Introduction the os as a myomatous polyp (Fig. 2). The relatively uncommon

Uterine myomas, the most common solid pelvic tumors in
women, occur in 20–40% of women in the reproductive years
and form the most common indication for hysterectomy [1].
They are benign lesions originating mainly from smooth muscles
of the uterus. However, the smooth muscle of the uterine blood
vessels may also be their source. Depending on their location in
the uterus, they may be subserous, intramural or submucous
(Fig. 1). They may, at times, acquire a stalk and project through
* Corresponding author at: 6/9J, Medical Campus, Pt. B.D. Sharma PGIMS, Rohtak
124001, Haryana, India. Tel.: +91 1262 213778.
E-mail addresses: nkadian@gmail.com, nkadian@rediffmail.com (N. Duhan).
extrauterine sites include the broad ligaments and the round
and uterosacral ligaments. Myomas may be solitary or multiple
and vary in size from seedlings to those filling whole abdomen.
Their growth is clearly associated with exposure to circulating
estrogen and hence a growth spurt is exhibited during
pregnancy and in the premenopausal years, secondary to more
anovulatory cycles. The estrogen receptors in myomas bind 20%
more estradiol (E2) per milligram of cytoplasmic protein than
the normal adjoining myometrium [2]. The tumors also
maintain high sensitivity to estrogen during the estrogen-
dominated follicular phase of the menstrual cycle, unlike normal
myometrium. However, this analogy fails to apply to adolescent
girls, who frequently have puberty menorrhagia due to
anovulation but no associated myomas.

0301-2115/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2010.05.010
120 N. Duhan, D. Sirohiwal / European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 119–125
Fig. 1. A large submucus myoma projecting into the cavity of a hysterectomy
specimen.
Out of the 202,538 patients between 20 and 50 years of age
examined in this tertiary care centre of North India in the last 10
years, 69,328 (34.22%) harboured myoma(s). Of the 64,093
abdominal hysterectomies carried out in the last decade at this
Institute, 34,268 (55.18%) were for solitary or multiple myomas.
2. Clinical features
The majority of women with uterine myomas are asymptom-
atic [3]. Among the symptomatic ones, the presentation usually
Fig. 2. A prolapsed anterior cervical lip bearing a myoma.
Fig. 3. A large necrotic myomatous polyp lying prolapsed outside the introitus.
correlates with size, site and concomitant degenerative changes in
these tumors. Excessive menstrual bleeding, on account of local
vascular changes in the endometrium, is the most frequent
symptom produced. Endometrial venule ectasia, increased endo-
metrial surface area, associated endometritis, dysregulation of
local growth factors and aberrant angiogenesis may contribute to
menorrhagia [3].
Pain is usually associated with torsion of a pedunculated
myoma, cervical dilatation by a submucous myoma tending to
negotiate through the os, carneous degeneration in pregnancy or
the extremely rare sarcomatous transformation. Fig. 3 depicts a
myomatous polyp which had prolapsed outside the introitus in a
postmenopausal woman after a fall. She had been consulting
physicians for pelvic and low back pain and had chosen to ignore
the occasional postmenopausal spotting. It is not advisable to
attribute pain to uncomplicated myoma.
Pressure effects on the adjoining urinary or gastrointestinal
tract may be caused by a cervical or an incarcerated posterior wall
myoma in the cul-de-sac. Rarely, a large myoma arising from the
uterosacral ligament may impinge on the bowel (Fig. 4).
Myomas rarely produce infertility. The incidence of myomas in
infertile women without any obvious cause of infertility is
estimated to be 1–2.4%. The relationship between leiomyomas
and infertility remains a subject of debate [4]. A submucous
myoma may distort the endometrial cavity and interfere with
Fig. 4. An intraoperative photograph showing a large, lobulated myoma originating
from the left uterosacral ligament in a 50-year-old woman.
 N. Duhan, D. Sirohiwal / European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 119–125
Fig. 5. A total hysterectomy specimen showing a large myoma on left side of uterus
and concomitant endometrial hyperplasia and polyposis.
sperm transport or blastocyst implantation or severely displace the
cervix out of the vaginal alignment. Distortion of the endometrial
cavity by myomas is associated with decreased pregnancy rates
and higher risk of spontaneous miscarriage after in vitro
fertilization [5]. Similarly, intramural myomas may cause obstruc-
tion/dysfunction of the fallopian tubes. Studies have reported an
improved reproductive outcome after myomectomy in otherwise
asymptomatic women [6].
Sarcomatous transformation in myomas is an extremely rare
event, occurring in 0.13–0.23% cases [7]. Considering that most
myomas are never removed, and not all those that are removed
undergo histologic evaluation, even this figure appears to be an
overestimation. However, an association of myomas with endo-
metrial hyperplasia and endometrial carcinoma has been reported,
the mechanism being hyperestrogenemia in all three. Around 28%
of endometrial carcinoma cases may have an associated myoma
[8]. Fig. 5 shows a hysterectomy specimen with a myoma and
concomitant endometrial hyperplasia.
3. Growth patterns
Rapid growth of a myoma is defined as an increase in uterine
size by 6 weeks’ gestational size in 1 year. Rapid growth of these
tumors in non-pregnant young women and in postmenopausal
women should arouse suspicion of malignancy, although the risk
of malignancy even in these women is very low [7]. As the uterine
size varies with the phase of menstrual cycle and the tissue
response to hormonal stimulation, 6-monthly pelvic examination
at a uniform time in the cycle is desirable.
Ultrasonography cannot only aid in evaluation of growth but
also detect pressure hydronephrosis. Intravenous pyelography is
only occasionally required as an aid to outline renal pelvicalyceal
and ureteral characteristics. Magnetic resonance imaging (MRI)
can discriminate a myoma from an ovarian mass better than
computed tomography. Hysterosalpingography may delineate the
contour of the endometrial cavity and fallopian tubes in infertile
women with myomas. Occasionally, peritoneal distribution of the
contrast media may outline the silhouette of a large pedunculated
subserosal myoma.
4. Treatment options
The treatment modalities for uterine myomas include
expectant management, medical therapy, conventional surgical
options and newer and less invasive approaches. Age, parity,
121
childbearing aspirations, extent and severity of symptoms, size,
number and location of myomas, associated medical conditions,
the risk of malignancy, proximity to menopause, and the desire
for uterine preservation are some of the factors affecting the
choice of therapeutic approach. Hence, the treatment should be
individualized.
5. Hormone treatment
GnRH analogues (GnRHa) have also been used successfully to
achieve hypoestrogenism both as a primary means of conservative
therapy for myomas or as an adjunct to myomectomy. Their effects
are transient and the myomas return to pretherapy size within a
few months of discontinuation [9]. The reduction in myoma
volume by preoperative GnRH analogue therapy may facilitate a
hysteroscopic resection of a submucous myoma with less blood
loss although the tissue planes tend to become more fibrotic and
adherent after this therapy [10]. The amenorrhoea induced by
preoperative GnRH analogue therapy may help in building up
hemoglobin levels, thus enabling presurgical blood donation for
subsequent autotransfusion. Menopausal symptoms, osteoporosis
and pelvic pain are some of the adverse effects of this therapy and a
hormonal add-back, if given, may negate the beneficial effects on
myoma size [11]. Danazol administration has been tried after 6
months of GnRHa therapy in an effort to prolong the therapeutic
effects of GnRHa. The bone mineral content that is substantially
reduced during GnRHa treatment is reported to significantly
improve with danazol, though a rebound of uterine volume due to
its antiprogesterone effect is a possibility [12]. In perimenopausal
women, however, a short-term GnRH analogue therapy may
eliminate the need for surgery.
Progestational agents are thought to produce a hypoestrogenic
effect by inhibiting gonadotropin secretion and suppressing
ovarian function, apart from exerting a direct antiestrogenic effect
at the cellular level. However, recent evidence that the anti-
progesterone mifepristone decreases myoma size raises concerns
about this mechanism [13]. Besides, the beneficial effects of these
agents are transient.
Use of levonorgestrel-IUD (LNG-IUD) is associated with
significant reduction in total myoma volume, average uterine size
and marked reduction in menstrual blood loss, though bleeding
disturbances may occur in about 68% women with its use [14].
6. Indications for surgery
Careful observation is suitable for most myomas as most of
them produce no symptoms, are confined to the pelvis, and are
rarely malignant [15]. Surgical options may be considered in cases
of abnormal uterine bleeding that is unresponsive to conservative
management, a high degree of suspicion of pelvic malignancy,
growth of myoma after the menopause, distortion of the
endometrial cavity or tubal obstruction in infertile women and
in those with recurrent pregnancy losses, pain or pressure
symptoms interfering with quality of life and anaemia secondary
to chronic uterine blood loss.
6.1. Hysterectomy
Hysterectomy is the most common major gynaecological
surgical procedure performed in women and 33.5% of these are
done for myomas [1]. Depending on the size, number and location
of the tumors, the skill of the surgeon and the availability of
instruments, apart from the open technique, laparoscopy and the
vagina are the other ports of access to the myoma-bearing uterus.
Hysterectomy has been the surgical procedure of choice for
myomas when childbearing considerations have been fulfilled or
122 N. Duhan, D. Sirohiwal / European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 119–125
Fig. 6. An operative photograph of enucleation of a true left broad ligament myoma.
when there is reasonable likelihood of malignancy. It is associated
with a high degree of patient satisfaction, eliminates the need for
progestational agents and enables the woman to take unopposed
estrogen therapy without many concerns. Nevertheless, it is not
free from complications. Adhesions and anatomic distortions of the
uterus pose an increased risk of damage to the urinary and
intestinal tract. Hysterectomy for broad ligament myoma has been
reported to carry a ureteric injury risk of 0.4/1000 [16]. Fig. 6
depicts the enucleation of a true broad ligament myoma while
Fig. 7 is an intraoperative picture of a false broad ligament myoma
and an enlarged body of uterus containing a solitary smooth
myoma. False broad ligament myomas tend to push the ureter
laterally and posteriorly, in contrast to true broad ligament fibroids
where the ureter is medial to the myoma. Knowledge of the precise
location and origin of the myoma as well as skill and experience of
the surgeon are of immense importance in order to avoid
inadvertent injuries to the urinary tract. Similarly, large cervical
myomas pose difficulty as well as increasing the risk of urinary
tract injury during the application of clamps on the Mackenrodt’s
and uterosacral ligaments.
Conservation of the cervix at hysterectomy has been proposed
to reduce the risk of subsequent vaginal vault prolapse and to
maintain good sexual function [17]. A supracervical hysterectomy
is also associated with a decreased risk of urinary tract injury and
requires less operating time. However, the need for cervical
Fig. 7. An intraoperative picture of a false broad ligament myoma and an enlarged
body of uterus containing a solitary, smooth myoma.
screening for cancer in women undergoing supracervical hyster-
ectomy is maintained. Around 61.4% women over 45 years of age
undergoing hysterectomy for myoma also undergo concomitant
bilateral ophorectomy [18]. Opinion regarding preservation of
apparently healthy ovaries continues to be divided. At least for
women less than 45 years of age, the ovaries should be spared.
6.2. Abdominal myomectomy
Myomectomy has been the procedure of choice for symptom-
atic myomas in women desiring retention of the uterus and often
for a solitary pedunculated myoma. However, the number of
tumors is no limitation for this procedure. Since submucous
myomas have been implicated in the aetiology of infertility and
recurrent pregnancy loss, myomectomy is recommended by some
before gonadotrophin stimulation for in vitro fertilization and also
in women with large myomas that may interfere with oocyte
retrieval [1]. Nevertheless, this continues to be a controversial area
and the removal of an otherwise asymptomatic large myoma
which does not distort the endometrial cavity may not be a
reasonable proposition in these cases. The procedure may be
considered in patients with large myomas, especially those with a
distorted endometrial cavity and in those with unexplained IVF
failure [12].
A thorough preoperative evaluation is advisable prior to
myomectomy. Women with menstrual irregularities and those
with risk of endometrial pathology require endometrial histologic
evaluation before myomectomy, particularly if aged more than 35
years. Hysteroscopy, if available, may be useful at the time of
endometrial sampling in diagnosing intrauterine pathology like
polyps, foreign bodies or forgotten intrauterine devices. In our
opinion, definitive surgery should be deferred for 4–6 weeks after
hysteroscopy so as to minimize the chances of disseminated
infection.
Optimization of the hematological status of the patient is of
paramount importance. The anemic woman should be pretreated
with GnRH analogues or progestational agents to produce
amenorrhoea. Stored autologous or donated blood should be
arranged for surgery.
The procedure can be carried out by laparoscopy (Fig. 8) or
laparotomy. A meta-analysis of six randomized controlled trials
(RCTs) and 576 patients suggests that laparoscopic myomectomy
is associated with less hemoglobin drop, reduced operative blood
loss, more patients fully recuperated at day 15, diminished
operative pain, and fewer overall complications but longer
Fig. 8. A laparoscopic myomectomy in progress.
 N. Duhan, D. Sirohiwal / European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 119–125
operation time [19]. The study concluded that if performed by
suitably specialized surgeons in selected patients, laparoscopic
myomectomy is a better choice than open surgery. However, the
quality of uterine repair would influence the risk of uterine rupture
during subsequent pregnancy. Hemorrhage and adhesion forma-
tion continue to be other areas of concern after myomectomy. The
therapeutic choice between myomectomy, hysterectomy or other
surgical options should be based on age and the desire for fertility
preservation.
The blood loss at surgery correlates with the uterine size,
weight of myomas removed and the operating time. Various
pharmacologic vasoconstricting agents and mechanical vascular
occlusion techniques have been tried to minimize surgical blood
loss. A meta-analysis of 10 RCTs and 531 participants analyzed the
various hemostatic measures used – intramyometrial vasopressin
and analogues, intravenous oxytocin, vaginal misoprostol, peri-
cervical tourniquet, chemical dissection with sodium-2-mercap-
toethane sulfonate (mesna), intramyometrial bupivacaine plus
epinephrine, tranexamic acid and enucleation of myoma by
morcellation while it is attached to the uterus [20]. All these
measures except oxytocin and enucleation by morcellation were
found to result in reduced bleeding at myomectomy, while
oxytocin and morcellation were not found to affect the operative
blood loss.
Isthmic myomas may be a class apart among myomas as far as
growth dynamics are concerned. They are reported to be subjected
to uterine peristaltic waves in opposite directions during different
phases of menstrual cycle, thus resulting in tangential growth [21].
This may pose difficulty in apprehending the extent and correct
anatomic relations at the time of surgery. Fig. 9 is a clinical
intraoperative photograph taken during myomectomy showing
the origin and the abdominal and cervical parts of a large myoma
arising from the isthmus of a normal sized uterus. The patient was
a 21-year-old nulliparous woman presenting with a lump in the
abdomen and infertility.
Adequate exposure, hemostasis, careful handling of reproduc-
tive tissues and adhesion prevention are some of the general
principles of abdominal myomectomy. The operative morbidity
associated with this procedure has not been shown to be any
higher than that of hysterectomy [22]. When extensive dissection
of the myometrium has been necessary during myomectomy,
irrespective of the actual opening of the endometrial cavity, a
subsequent cesarean delivery is advisable.
Fig. 9. An operative photograph taken during myomectomy of a huge anterior
isthmic myoma with both intracervical and abdominal extensions. The normal
sized body of uterus is visible behind the large myoma.
123
6.3. Hysteroscopic myomectomy
This procedure is indicated for abnormal bleeding, history of
pregnancy loss, infertility and pain, while suspicion of endometrial
malignancy, inability to distend the cavity or circumnavigate the
lesion and tumor extension deep into the myometrium are the chief
contraindications. Around 20% women will need additional therapy
within 10 years of this procedure, mainly due to incomplete removal
or new myoma growth [1]. The European Society of Hysteroscopy
classifies submucous myomas according to the extent of myometrial
invasion into four categories to help the hysteroscopist plan the
surgical approach [23]. Category T:O includes all pedunculated
submucus myomas. Submucus myomas extending less than 50%
into the myometrium are classified as T:I, while those with greater
than 50% penetration are classified as T:II. Category T:O and T:I can
be removed hysteroscopically by a surgeon with modest previous
experience while category T:II myomas should be resected
abdominally, and hysteroscopic resection should be reserved for
highly skilled hysteroscopic surgeons. Fig. 10 depicts the procedure
of hysteroscopic myomectomy.
Reduction in myoma volume by preoperative GnRHa therapy
may facilitate hysteroscopic resection of a submucus myoma with
less blood loss although the tissue planes tend to become more
fibrotic, adherent and less clear after this treatment [10].
6.4. Laparoscopic/robotically assisted laparoscopic myomectomy
Superficial subserous or pedunculated myomas are best suited for
laparoscopic or robotically assisted laparoscopic removal. Their
removal is effected by either morcellation, utilization of a colpotomy
incision or myolysis. Laparoscopic myomectomy in infertile women
with intramural myomas offers comparable results to laparotomy
and the pregnancy rates tend to be affected by other associated
infertility factors [24]. Uterine rupture during pregnancy after
laparoscopic myomectomy has been attributed to inadequate
reconstruction of myometrium during surgery. All women wishing
to undergo myomectomy should be willing for a hysterectomy, if
need be. The finding of diffuse leiomyomatosis in a woman posted
for myomectomy is not uncommon. For those who desire concep-
tion, a delay of 4–6 months before attempting pregnancy is
recommended after myomectomy to allow for myometrial healing.
6.5. Uterine artery embolization
This procedure, first described for management of myomas in
1995, attempts to limit growth by limiting the blood supply.
Fig. 10. An operative picture of hysteroscopic myomectomy.
124 N. Duhan, D. Sirohiwal / European Journal of Obstetrics & Gynecology and Reproductive Biology 152 (2010) 119–125
Polyvinyl alcohol particles are passed through a fluoroscopically
guided transarterial catheter inserted in the common femoral
artery to selectively occlude the arteries supplying the myoma.
This short interventional radiologic procedure requires a
short hospital stay and is recommended for large symptomatic
myomas in women who do not wish or are poor candidates for
major surgery. Goodwin et al. reported the long-term outcomes
from the FIBROID Registry based on a 3-year study of 2112
patients who underwent uterine artery embolization for
symptomatic leiomyomas [25]. The procedure was found to
be associated with improvement in quality of life and a
subsequent need for hysterectomy, myomectomy or repeat
uterine artery embolization in 9.79%, 2.82% and 1.83%
patients, respectively. Persistent ischemic pain, postemboliza-
tion fever, severe postembolization syndrome, pyometra, sepsis,
hysterectomy and even deaths have been reported after the
procedure [26]. Ovarian failure may ensue in 1–2% patients,
though successful pregnancies too have been reported after
embolization [27].
6.6. Magnetic resonance-guided focused ultrasound surgery
(MRgFUS)
In October 2004, the United States Food and Drug Adminis-
tration (FDA) approved MRI-guided focused ultrasound treat-
ment of uterine fibroids in humans, which is being sold as
ExAblate in the US. The rise in temperature of the tissue
receiving the high intensity focused ultrasound (HIFU) and the
resultant protein denaturation and irreversible cell damage form
the basis of this treatment modality [28]. A reduction of up to
98% in myoma volume and symptoms has been reported with
this non-invasive treatment for symptomatic myomas [29].
However, the efficacy of MRgFUS correlates with signal intensity
of T2-weighted magnetic resonance images. Those with low
signal intensity on pretreatment images are more likely to
shrink than those with high signal intensity [30]. The larger the
non-perfused volume (NPV) immediately after treatment, the
greater are the volume reduction and symptom relief. Thus,
Type 1 and 2 fibroids are suitable for this treatment while Type 3
myomas are not [31].
6.7. Myolysis
Various forms of myolysis – bipolar, cryo, radiofrequency,
laparoscopic and MRI-guided laser – have been tried as conserva-
tive alternatives to myomectomy in women desiring uterine
preservation [32,33]. Carbon dioxide laser has been used to directly
vaporize small myomas at laparotomy, while medium and large
myomas are excised. Improved hemostasis and greater precision at
removal appear to be the chief advantageous but the technique has
not been tested in larger series of patients. Some submucous
myomas have been successfully treated by Nd:YAG laser which
devascularises the myoma, however, incomplete removal may be
an issue of concern at times.
7. Comments
A clear understanding of the pathogenesis, clinical presentation
and available management tools is vital for successful treatment of
any woman with myomas. Various factors affect the choice of the
best treatment modality for a given patient. Asymptomatic
myomas can be managed by reassurance and careful follow up.
Medical therapy should be tried as a first line of treatment for
symptomatic myomas while surgical treatment should be reserved
only for appropriate indications. Hysterectomy has its place in
myoma management in its definitiveness. However, myomectomy,
rather than hysterectomy, should be performed when subsequent
childbearing is a consideration. Preoperative GnRH analogue
treatment before myomectomy decreases the size and vascularity
of the myoma but may render the capsule more fibrous and
difficult to resect. Uterine artery embolization is an effective
standard alternative for women with large symptomatic myomas
who are poor surgical risks or wish to avoid major surgery. Its
effects on future fertility need further evaluation in larger studies.
Serial follow-up without surgery for growth and/or development
of symptoms is advisable for asymptomatic women, particularly
those approaching the menopause.
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